2On 11/10/095 months child presented with 5 days history of loose motion
3for 3-4 times daily (normal 1-2 times/day) for 3-4 times daily (normal 1-2 times/day). the diarrhea was associated with low grade fever ( not ducomented )2 times vomiting only
4the fever was of low grade in nature, on/off with no sweating, rigors/chills, abdominal pain, respiratory distress, LOC or seizures.Mother noticed blood in the stool at 11:30pmh/o increased crying.perinatal history is not eventful
5Examination: looks lethargic and dehydrated. No pallor, jaundice, cyanosis, LN.HR=140/mint, RR=30/mit, t=36.9 C, O2 sat=98%, BP: 86/ wt:8 kgAbdomen: soft, no distention , tenderness, no mass.Other systemic examination: nad.
13d/c on ORSit was fully explained for the parents if the patient developed fever, bloody diarrhoea or vomiting to bring her back to the A&E or nearest local health center
14On 13/10/09h/o vomiting x several times, poor oral intake persisting loose watery stools / mixed with blood ? red current jelly stoolsNo excessive (Inconsolable) crying
15Examination:afebrile, tachycardic 158/min, rr 28/min looks mod-sev dehydrated with dry mucus membrane, mild sunken eyeballs and ant fontanelle.chest: clear sat 100%P/A: soft, non tender, + bs, no mass
17US abdomen: (13/10)There was a donut sign seen in the right mid abdomen suggestive of intusseption. After manipulation is resolved spontaneously. The spleen, liver, GB and both kidneys are normal. No free fluid in the pelvis or abdomen. \ Spontaneous resolution of Colico-colic intusussception
18Admitted for observation -NPO -start IVF 0 Admitted for observation -NPO -start IVF 0.18 DNS 30 cc/hr -ceftriaxine 170mg IV OD
25EPIDEMIOLOGY 2 per 1000 live births. male-to-female ratio is 3:1. Most common between 3-9 monthmost common cause of intestinal obstruction between 6 and 36 months of ageMost episodes occur in otherwise healthy and well-nourished children
26Approximately 60 percent of children are younger than one year old, and 80 percent are younger than twoIntussusception is rare before three months and after six years of age
27Most patients recover if treated within 24 hours Most patients recover if treated within 24 hours. Mortality with treatment is 1-3%. If left untreated, this condition is uniformly fatal in 2-5 days. Recurrence is observed in 3-11% of cases. Most recurrences involve intussusceptions that were reduced with contrast enema
28History Abdominal pain(80-95%) : The child appears to have intermittent abdominal pain( manifest as episodic bouts of crying) which is colicky, severe and may be accompanied by pallor and drawing up of the legs (guarded position)Episodes typically occur 2-3 times/hour.Infant may sleep or may appear lethargic or playful between episodes of pain.
29classic red currant jelly stool is a late sign (60%) Vomiting (75%)is usually a prominent featureInitially nonbilious but may progress to biliousBowel motionsblood and/or mucusclassic red currant jelly stool is a late sign (60%).( so bilios vom is a late )
32Diarrhea is quite common and can lead to a misdiagnosis of gastroenteritis .(can be an early sign of intussusception )Lethargy is a relatively common presenting symptom with intussusceptionThere may be a preceding respiratory or diarrheal illness
33Classic triad(21% all three, 72% have two) 1-Intermittent abd. Pain(80-95%)2-Bilious vomiting(75%)3-Currant-jelly stool(60%)
34ExaminationAbdomen:Abdominal mass(65%) - sausage shaped mass in RUQ or mid-abdomen variably tenderAbdomen may be soft, non-tender or distended and tender( This is hard to detect and is best palpated when the infant is quiet between spasms of colic. )( dependeing in cmplet virsus incomplet obs or presense pf pertonitis)
35Peristaltic wave may be present. Absence of bowel contents in RLQ ( Dance sign)PR: may revealed blood or mass. (PR unnecessary if good evidence of intussusception).(u may palpate spex of intracss., u should be able to defrinniitae betweenit and rectal prolapse
36Investigations Blood tests FBC, U&E Blood group and cross -match Blood glucoseCbc for leukocytosis, ue for dehydration
37Plain abdominal XrayPerformed to exclude perforation or bowel obstructionA normal AXR does not exclude intussusceptionradiographic signs of intussusception are subtleSigns of intussusception on a plain Xray include :
381-Target sign - two concentric circular radiolucent lines usually in the right upper quadrant 2-Crescent sign : intussusceptum protruding into a gas filled pocket, which often results in a crescent shaped gas pocket.3-Signs of obstruction.( dilated small bowel, fluid levels, minilmal fecal content of colon
40Sensitive and specific. Ultrasound scan :Useful if there is a suggestive history but no mass palpable or signs on plain AXRSensitive and specific.Its use is limited by diagnostic and therapeutic use of air enemaDonut sign: hyperechoic core surrounded by hypoechoic rim
42This intervention is both diagnostic and therapeutic Hydrostatic reduction( air or barium)This intervention is both diagnostic and therapeuticDiagnostic investigation of choice if high level of suspicionSucuss rate is 80-90%, recrrence is 10%(most within 24 hr post reduction)
47Management Initial stabilization: Secure IV access Most children will require fluid resuscitation with normal saline 20mls/kg IVKeep nil orallynasogastric decompressionSurgical consultation.It is very important that this condition is diagnosed and treated early
48recrrence is 10%(most within 24 hr post reduction) Hydrostatic reductionSucuss rate is 80% in <24h of intrassusception. Only 32% if >24h.,recrrence is 10%(most within 24 hr post reduction)CI: peritonitis, perforation, shockComplications: perforation, reduction of necrotic bowel.
49Surgical reduction: indicated in: 1-suspected bowel gangrene or perforation.2 -failure of hydrostatic reduction3-multible recurrence.
50Clinical pearlsIntussusception is the most common cause of intestinal obstruction between 3 months and 2 years of age.high index of suspicion is essential60% of Intussusception are initially misdiagnosed( GE is commonly confused with it)( please remember)
51Colicky abdominal pain is the major symptom Bilious vomitous and currant jelly stool are late findingProfound Lethargy can be the sole presenting symptom (up to 10%) , which makes the diagnosis challengingMorbidity and mortality increased with delayed diagnosis.